VERIFIABLE CPD PAPER

CLINICAL Restorative dentistry

Alveolar ridge preservation: why, when and how

Amardip S. Kalsi,*1 Jagdip S. Kalsi2 and Steven Bassi3

Key points
Alveolar ridge preservation can prove beneficial for Provides an assessment of the evidence and materials Suggests a clinical protocol for alveolar ridge
implant and pontic sites in certain cases. involved. preservation.

Abstract
Alveolar ridge preservation (ARP) is a method of decreasing bone resorption following tooth extraction and facilitating
prosthetically-driven implant placement. An understanding of the physiological responses occurring after extraction and
the effects of ARP are important in order to implement clinical procedures. ARP is a predictable way to reduce undesirable
horizontal and vertical ridge reduction following extraction when dental implant treatment is to be delayed. Guided bone
regeneration, socket fillers, socket sealers and growth factors have been used satisfactorily. However, there is currently
no consensus on case selection, best clinical technique and material choice. Management of tooth extraction sockets is
presented, with a focus on decision-making.

Introduction Table 1 Recommendations for ARP depending on socket anatomy16

Alveolar ridge preservation (ARP) is ‘a
procedure to arrest or minimise alveolar
ridge resorption following tooth extraction
for future prosthodontic treatment including
placement of dental implants’.1 ARP was first
described as ‘bone maintenance’ in 1982,2
and is synonymous with socket preservation,
ridge preservation, socket grafting and socket
augmentation. ARP commits to delaying
implant placement by at least three to six
months after extraction,3,4 with potentially
longer treatment times compared with
immediate and early (up to four months)
implant placement.
ARP involves the use of a variety of graft
materials, whether host-derived or transplanted,
in order to fill an extraction socket and, usually,
cover it immediately following tooth removal.5
This contrasts with ridge augmentation, which
1
Speciality trainee Registrar in Restorative Dentistry;
3
Consultant in Restorative Dentistry, Eastman Dental
Hospital, 47-49 Huntley Street, London WC1E 6DG;
2
Consultant in Restorative Dentistry, Croydon University and
King’s College Hospitals, 530 London Rd, Croydon, UK.
*Correspondence to: Amardip Kalsi
Email: amardip.kalsi@nhs.net
Refereed Paper.
Accepted 24 April 2019
https://doi.org/10.1038/s41415-019-0647-2
Type of extraction
Description of socket
socket
Type I All bone and soft tissue preserved
Labial defect (for example, buccal
Type II
dehiscence or fenestration)
Type III Labial and interproximal vertical defect
aims to increase the ridge volume beyond the
existing skeletal envelope either at the time of
extraction, before, or at implant placement.6 The
potential advantages of ARP include maintenance
of the existing soft and hard tissue envelope, a
stable ridge volume for optimising functional
and aesthetic outcomes, and simplification
of subsequent treatment procedures such as
generation of good soft and hard tissue volume
for the time of implant placement.6
The aim of ARP is to maintain horizontal and
vertical alveolar ridge form using bone grafts
(autografts, allografts, xenografts or alloplastic
materials); soft tissue grafts; guided bone
regeneration (GBR) (with resorbable or non-
resorbable barriers), biologically-active materials
(growth factors) or combinations7 to reduce the
loss of coronal alveolar bone height and width.
Allografts are defined as grafts between the
same species and xenografts from a different
species. Autografts are those harvested and
applied within one individual. Alloplasts are
Recommendation for augmentation
Bone graft and membrane, bone graft
alone, membrane alone or no graft
Bone graft and membrane
Orthodontic extrusion before extraction
synthetic materials. With the advent of a growing
array of choices in materials, there is much interest
in the best material and technique for ARP. No
less than ten systematic reviews on the subject
have been published since 2009,1,3,7,8,9,10,11,12,13,14
and the literature does not support the use of one
technique, or material, as superior.
There is currently no consensus for case
selection, clinical technique, or material
choice. 1,9 Alternatives to ARP, such as
immediate and early implant placements, offer
similar implant outcomes in the shorter term.15
The key to successful implant outcomes,
regardless of the time of implant placement, is
planning how to manage the bone volume at
the proposed site. Salama and Salama16 have
made recommendations for the ARP method
that should be utilised depending on the socket
anatomy (Table 1).16 This article aims to outline
the current underlying evidence and methods
of ARP, and provide guidance to aid clinical
decision-making.

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 Restorative dentistry CLINICAL

Alveolar ridge changes following Fig. 1 Stages in socket healing

tooth extraction
Day 0:
After extraction, a blood clot forms which is Blood clot fomation in socket
followed by formation of granulation tissue.
Mineralisation then occurs, forming woven
bone, which is later remodelled to lamellar Day 4-5
Conversion of blood clot to granulation tissue
bone.17 Bony changes after tooth extraction
can occur for a number of months, with most
changes occurring in the first three months.18
Day 5-16:
A summary of this process is shown in Converstion to connective tissue matrix
Figure 1.19,20,21 Bundle bone, also known as the Bundle bone (lamina dura) lining the extraction socket resorbs, allowing blood
vessel proloferation from surrounding marrow space
lamina dura, lines the periodontal ligament
around a tooth and is always resorbed after
tooth extraction, regardless of whether an
3-6 weeks:
implant is placed immediately or not. Its Osteogenesis: Formation of woven bone from periphery of socket inwards
thickness is 0.2–0.5  mm22 and it is fully Soft tissue barrier created over socket entrance
resorbed by four weeks after extraction.23
A 50% reduction in the bucco-lingual width
of bone has been estimated, in addition to a 5-10 weeks:
Remodelling to form trabecular bone and corticalistion of socket entrance
decrease in bone height at 12 months after Supracrestal soft tissue reorganises into mucosa continuous with that surrounding it
extraction.18 Two-thirds of this reduction
happens within three months. A recent
systematic review reported mean alveolar bone
resorption of 3.8 mm in width and 1.24 mm
in height over the first six months following
extraction.24 The buccal aspect of bone resorbs
at a faster rate, resulting in a lingual shift in the
bone crest with more pronounced resorption
in the mandible.25,26,27 Where the buccal bone
wall is 1 mm or narrower after tooth extraction,
a median vertical bone loss of 7.5 mm of this
buccal wall can be expected at eight weeks
post-extraction. If buccal bone thickness is
Fig. 2 A case of early implant placement in the 12 site. a) Extraction socket. b) Implant
more than 1 mm after extracting a tooth, only
placement with GBR 2 months later. A 3.4 mm diameter fixture was placed in 12 that led to
1.1 mm vertical loss of the buccal wall occurs.28 exposed palatal threads at an angulation requiring a cement retained restoration
Ridge resorption has been suggested to occur
due to disuse atrophy, a lack of blood supply
and inflammation.29 Systemic and anatomical choice between a screw and cement-retained 2. When patients are not available for
factors are likely to have an influence on the restoration is often limited by the apical aspect immediate or early implant placement
amount of resorption that occurs.17 These may of the buccal envelope, not coronal ridge height 3. When primary stability of an implant
include immunosuppression, impaired healing, and width. As ARP minimises the loss of cannot be obtained
genetics, smoking, periapical infection, chronic coronal alveolar bone, it does not influence the 4. In adolescent people
periodontitis, historical trauma, socket wall prosthodontic implant restoration as much as the • Contouring of the ridge for conventional
integrity, the number of adjacent teeth extracted, position of the alveolus. prosthetic treatment; for example, pontic
surgical trauma and prosthesis design.21,30 site development
These physiological changes following Indications • The cost/benefit ratio is positive.
tooth extraction can affect optimal dental Consideration may be given to the cost
implant positioning.31 An example is shown in The following indications are based on an of ARP at the time of tooth extraction
Figure 2 which depicts a case with early implant Osteology Workshop’s recommendations for compared with the likelihood of GBR at a
placement. A narrow diameter fixture was placed ARP.6 ARP is used where tooth extraction is later date and its associated cost
in the 12 site that led to exposed palatal threads required and delayed dental implant placement • Reducing the need for elevation of the
at an angulation requiring a cement-retained in that site is likely at some point: sinus floor.
restoration. Although ARP could have slightly • Implant placement is planned at a time
reduced the risk of these problems, there is point later than tooth extraction, such as: Some patients may be unable to commit
limited evidence that further grafting is avoided 1. When immediate or early implantation financially to immediate or early implant
or that the implant position is improved.9 The is not recommended placements and may therefore wish to keep their

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 CLINICAL Restorative dentistry

Table 2 Indications and limitations of treatment modalities in ARP. Reproduced with permission from Jung R E et al. Alveolar ridge
preservation in the esthetic zone. Periodontol 2000 2018; 77: 165–175, Wiley.
Treatment option Aim Clinical indications Limitations
Ankylosed teeth with vertical soft tissue Teeth with acute infections.
Soft tissue Improve the quantity and quality of soft deficiencies. Large bone defects.
preservation tissues at the time of tooth extraction Teeth with soft tissue recessions. Technique sensitive in terms of soft tissue management
Teeth lacking keratinised tissue in sites with extensive soft tissue defects
Small buccal bone defects (less than 50% of
the buccal bone plate missing), with or without The socket seal technique does not allow for 100%
Hard and soft tissue Regenerate and preserve the hard
soft-tissue defects. preservation of the ridge contour and therefore
preservation tissue and the soft tissue at the time of
As a method for implant placement 4–6 months needs, in highly aesthetic areas, a further small
(socket seal) tooth extraction without flap elevation
thereafter contour augmentation
Pontics of conventional reconstructions

Hard tissue Large buccal bone defects (>50% of the buccal Invasive surgery at the time of tooth extraction
Regenerate and augment the alveolar
preservation (guided bone plate missing), scheduled for late (>6 without implant placement.
bone at the time of tooth extraction
bone regeneration) months) implant placement Long healing time

Fig. 3 Flow chart for decision-making in ARP

Tooth-In-Situ
Implant planned requires extraction Implant not currently planned

Immediate implant placement feasible?

(patient and clinician factors) Viable future implant site?

No Yes No Yes

Extensive bone grafting clearly indicated? Immediate implant Aesthetic Pontic Site? Patient considering implant
(eg severe hypodontia and retained primary teeth) placement in the longer term?

No Yes No Yes No Yes

Can implant placement Extraction(s) block grafting and

Extract without Extract without
proceed without delay? implant placement without ARP ARP ARP
ARP ARP

No Yes

Early implant planning and

ARP
placement without ARP

options for delayed implant placement open, in
which case ARP may be an appropriate option.
Recently, a clinical decision tree described the
clinical indications and limitations (Table 2),32
for soft tissue, hard and soft tissue, and hard
tissue preservation. Hard tissue preservation was
proposed for sockets with more than 50% loss of
the buccal plate requiring ridge augmentation,
and is therefore not part of our review.
Additionally, the authors would consider
ARP when significant bone resorption is
likely to impact on ideal implant placement.
More than 1.8 mm of buccal bone is required
following osteotomy for implants to minimise
the risk of resorption.33 An evaluation of buccal
bone thickness around teeth in the anterior
maxilla showed that 90% had bone of less than
1 mm thickness.34 This suggests that ARP can
be beneficial in these sites to provide a ridge
with more than 1 mm thickness of buccal bone
following osteotomy. A flowchart for decision-
making regarding ARP is shown in Figure 3.
Evidence is lacking regarding predictive
factors for the success of ARP. It is felt that
routine surgical precautions should be taken
and, in accordance with this, outcomes could
potentially be affected by local and systemic
factors. If extensive bone grafting is likely
to be required in the future, the use of ARP
techniques is most probably negated.
Outcomes
A recent Cochrane review identified eight
studies with a follow-up of over six months
assessing the outcomes of ARP using a variety
of surgical methods, including with and
without primary closure.1 Of the eight studies
included, seven were at a high risk of bias and
one was unclear. Consolidating the studies gave
results from 233 extraction sites in 184 healthy
adults. Exclusion criteria included significant

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Table 3 Results of a systematic review comparing ARP using xenografts and allografts
with extraction alone1
Comparison
ARP with xenograft compared with extraction alone
ARP with allograft compared with extraction alone
ARP with xenograft compared with ARP with allograft
*Greater bone volume with bone graft material
infections in or close to the site, a full mouth
plaque score over 30%, parafunction and
participants smoking more than ten cigarettes
per day. Most of the results were from four-
walled sockets and implants were placed at
least six months after ARP. Table 3 summarises
the results of the systematic review. The studies
showed ARP will decrease the amount of
residual ridge resorption, however some bone
loss will still occur.
ARP with xenograft or allograft showed
around 2 mm less decrease in alveolar bone
height and width compared with extraction
alone. There was insufficient evidence to show
differences between techniques regarding
the amount of augmentation possible,
complications, implant failure, changes in
peri-implant bone levels and probing depths
of neighbouring teeth. There are currently
no trials assessing clinical attachment levels,
aesthetic or prosthodontic outcomes with
regards to ARP. The systematic review
concluded that, at six-month follow-up,
subjects have more bone, regardless of the
materials or methods used for ARP.
While ARP was shown to be effective,
some authors have argued that it causes
hindrance of normal socket healing, has no
benefit,35 and particles of different grafting
materials may remain in the extraction socket
for more than six months.36 A systematic
review assessing the quality of grafted bone
in sockets having undergone ARP with a
variety of materials compared with naturally
healed sockets identified eight studies, which
showed considerable residual graft particles
present (15–36%), at a mean of 5.6 months
after ARP depending on the material used.37
A significantly decreased percentage of
connective tissue (ranging from 17.9% to
33%) and an increased percentage of vital bone
(ranging from 6.2% to 23.5%) was found in
sockets having undergone ARP. Traditionally,
a delay of six months has been advocated
between ARP and implant placement, although
the amount of vital bone available is similar at
three and six months.38
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Restorative dentistry
Difference in alveolar Difference in alveolar
bone height (mm) bone width (mm)
2.6* 1.97*
2.2* 1.97*
No difference No difference
Residual particles may interfere with normal
healing and bone-to-implant contact. The
degree of change in bone quality depends on the
resorption rate of the graft material and its ability
to encourage bone formation. Xenografts, which
are increasingly used for ARP, have been shown
to leave around 30% of residual material present,
which is usually encapsulated within connective
tissue.37,39,40 It is unknown whether this interferes
with vital bone formation, but it is possible that
decreased bone density caused by residual graft
material could affect primary stability and
additionally decrease implant-to-bone contact. In
contrast, animal studies have shown that residual
xenograft particles are separated from implant
surfaces by mineralised bone.41,42 This would
warrant further investigation.
A recent systematic review investigated the
influence of ridge preservation on implant
outcomes and concluded:9
1. Alveolar ridge preservation procedures
may decrease the need for further ridge
augmentation during implant placement
in comparison to unassisted socket healing
2. There is no evidence to support the fact that
implant placement feasibility is increased
following ARP in comparison to unassisted
socket healing
3. The survival, success and marginal bone
levels of implants placed in alveolar ridges
following ARP are comparable to that of
implants placed in untreated sockets
4. No evidence was identified to inform on the
possible superior impact of a type of ARP
intervention (GBR, socket filler and socket
seal) on implant outcomes. Currently, it is
unknown if one biomaterial or treatment
protocol is superior to another
5. The majority of the studies evaluating implant-
related outcomes after ARP procedures
are presenting high or unclear risk of bias.
Therefore, any clinical recommendation
derived from these studies should be applied
with caution.
Immediate and early implant placements
offer the advantage of shorter implant treatment
CLINICAL
times. However, a recent systematic review
has suggested that implants can be placed at
3–4 months after ARP, regardless of the bone
substitute that is used, but the results and
conclusions were based on a number of studies
with no power calculations or intention to treat
analysis.4 It is often an individual clinician’s
preference whether to place implants so early
in grafted sites, but the clinical experience of
the authors would suggest waiting at least six
months before placing implants to allow graft
maturation is preferable. The literature does not
address the influence of preserving ridges on
achieving ideal implant selection and position.9
Consent
ARP is carried out to maintain bone volume
following tooth extraction, usually to aid
prosthetically-driven implant placement.
Patients should be informed of the procedure
and specifically of the proposed materials to
be used. They should be informed that ARP
would involve a longer surgical time than
extraction alone. Some patients may decline
the use of xenograft materials due to religious
or other beliefs and alternative materials can
be utilised.
Surgical risks include bleeding, bruising,
soreness, the need for sutures, infection, risk of
damage to adjacent structures, recession, graft
exposure, breakdown and failure. Additionally,
patients should be informed that ARP cannot
guarantee enough bone availability for implant
placement and that further bone or soft tissue
augmentation may still be required. The
alternative option of extraction without ARP
should also be discussed.
Materials
Methods include the use of a graft alone, the
use of a graft and soft tissue graft/ membrane,
or a membrane alone. Each method can be
carried out with or without primary closure.
Guided bone regeneration (GBR)
The principle lies in preventing gingival
epithelial and connective tissue from entering
the defect via cell occlusive membranes in
order to allow specific cells to regenerate lost
tissues in the defect. A number of products are
available for ARP and the materials often come
in a number of different forms; some examples
are shown in Table 4.
Barrier membranes are often utilised to
maintain space for bone growth. These can
 CLINICAL
Table 4 Bone graft and membrane materials available for ARP
Material
Bone graft materials
Tetracycline hydrated freeze-dried bone allograft
Demineralised freeze-dried bone allograft
Porcine derived coritocancellous bone mix and
collagen membrane
Deproteinised bovine bone material
Deproteinised bovine bone material and porcine collagen
Hydroxyapatite and ß-tricalciumphosphate material
Nanocrystalline hydroxyapatite (bio active glass)
Biphasic calcium phosphate
Beta-tricalcium phosphate
Membrane materials
Acellular dermal matrix
3D collagen matrix
Collagen barrier membrane
be either resorbable or non-resorbable. Non-
resorbable membranes show larger bone fill
and favourable marginal tissue response.
Resorbable membranes do not require second
surgery for their removal and show good soft
tissue healing.1
Non-resorbable membranes
These may be constructed of cellulose
acetate filters (Millipore) or expanded
polytetrafluoroethylene (e-PTFE or Teflon).
Titanium has also been built into e-PTFE
membranes to reinforce the structure and
allow the membrane to tent up to maintain
space for bony infill. e-PTFE alone has been
shown to provide a gain in new bone formation
of 1.5–5.5 mm at six to ten months.43
The negative aspects of non-resorbable
membranes have meant they are less widely
used more recently. A second surgery is required
for their removal, which increases morbidity.
Membrane exposure is relatively common due
to extrusion, in turn significantly impairing
healing and regeneration. To counteract this,
high-density polytetrafluoroethylene (d-PTFE)
has been developed. When left exposed for
up to four weeks, no impairment of healing
occurs. This means d-PTFE does not require
releasing incisions to close the flap.44
Resorbable membranes
These include polyglycoside synthetic
copolymers, collagen and calcium sulphate.
These membranes have the advantage of not
requiring a second surgical procedure for
their removal. Collagen has the following
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Restorative dentistry
Trade name
– Human
– Human
OsteoBiol Gen-Os
Bio-Oss
Bio-Oss Collagen
Symbios Biphasic bone graft material
NanoBone
Straumann Bone Ceramic
Resorbable tissue replacement (Septodont)
Alloderm
Mucograft
Bio-Gide membrane
benefits, which may assist in clot formation
and stabilisation, and hence regeneration:
• Acts as a haemostatic agent
• Stimulates platelet attachment
• Enhances fibrin linkage
• Attracts fibroblasts
• Easy to manipulate
• Adapts to bone.
Despite these advantages, resorbable
membranes have not been shown to give more or
less bone than non-resorbable, although they are
less likely to undergo exposure and infection.45,46
Acellular dermal matrix (ADM) is human
skin tissue that has undergone repeated
washing followed by freeze-drying. It was
originally developed for burn victims and
in dentistry is mostly used for mucogingival
procedures in periodontal surgery. In ARP,
ADM has been shown to preserve ridge
thickness and this effect can be enhanced by
the use of hydroxyapatite, which also helps to
increase the width of keratinised tissues.47
Socket grafts
Socket graft materials work via osteoinduction
and/or osteoconduction. Osteoinduction is the
stimulation of bone growth via mesenchymal
cells differentiating into osteoblasts. The most
common material that facilitates this process
is autogenous bone chips. Osteoconduction
involves capillary and progenitor cell
formation in and around the graft material,
which acts like a scaffold. Most materials work
via this method. Membranes can be used in
combination with socket grafts.
Autografts
Extra-oral, for example, iliac crest and marrow
Origin block autografts, and intra-oral, for example,
ramus of the mandible, maxillary tuberosity,
post-extraction healing sites and bony
exostoses are not used routinely for ARP due
the relatively high morbidity.
Animal Cancellous bone provides more osteogenesis
than cortical bone, likely due to the abundance
Animal
of cells in the marrow.48 Intra-oral autografts
Animal
can be harvested as osseous coagulum, where
Plant bone is harvested with burs and mixed with
Synthetic blood, or bone blend, where harvested bone
Synthetic is triturated in a sterile amalgam capsule for
Synthetic 60 seconds.49 Commonly, bone is harvested
via the use of a bone trap or scraping hand
instruments, for example with a Rhodes back
Human
action chisel.
Animal
Animal
Allografts
The benefit is decreased morbidity due to the
lack of a second surgical site. There are two
types, mineralised frozen or freeze-dried
bone (FDBA) and demineralised frozen or
freeze-dried bone (DFDBA). FDBA works via
osteoconduction and is resorbed more slowly
than DFDBA. DFDBA may have the advantage
of osteoinduction. These grafts are stored in
tissue banks. These banks are not standardised,
save for prevention of disease transmission,
and allografts are obtained and prepared in a
variety of ways.50 Tissue banks will screen and
accept donors in a variety of ways, however all
high risk groups for transmissible infections
or Creutzfeld-Jakob disease are excluded as are
donors with human immunodeficiency virus
(HIV), hepatitis B, hepatitis C and Treponema
pallidum (syphilis). Donors with malignancies
are not specifically prohibited. In addition to
taking a history, autopsies, blood tests and
bone marrow cultures must be performed
on potential donors. Autopsies have found
considerable discrepancies compared with
clinical diagnoses.50
DFDBA and FDBA show no difference
in alveolar ridge dimension following ARP,
however DFDBA shows greater vital bone
(38.45% versus 26.63%) and less residual
graft particles (8.88% versus 25.42%) at 4–5
months.51
The ideal particle size of these grafts has
been suggested to be between 100–380 μm, as
smaller particles are resorbed by macrophages
and larger particles restrict space for
vascularisation and additionally can be
sequestered.52,53 Bone blend has the smallest
particle size (21 x 105 μm), followed by osseous

Table 5 Summary of findings of systematic review by Jambhekar et al. 201577
Mean loss of bucco- Mean loss of buccal wall
Material lingual width at ridge height from ridge crest
crest (mm) (mm)
No ARP 2.79 1.74
Xenografts 1.3 0.57
Allografts 1.63 0.58
Alloplasts 2.13 0.77
coagulum and FDBA (300–500 μm). Chiselled
bone chips are the largest (789 x 1,559 μm).53
No differences have been found between
DFDBA bone putty of different particle sizes
in biopsies taken 20 weeks after ARP.54 When
comparing cortical and cancellous FDBA, no
difference in bone formation has been found
but a greater loss of lingual ridge height was
found in the cancellous group.55
Xenografts
DBBM is the most commonly used xenograft.
Trade names include Bio-Oss, Cerabone,
DirectOss and Hypro-Oss. Specimens taken
nine months after ARP have demonstrated
26.4–35.1% vital bone, with coronal portions
mostly formed of connective tissue (63.9%).
The material was also present throughout
the anterior maxillary sites, taking up
approximately 30% of the volume.39 Most
particles contact with cortical bone and
minimally contact connective tissue. DBBM
works primarily by osseoconduction56 and
resorbs at a rate of 10% per year.57
Bio-Oss collagen, consisting of 90% DBBM
and 10% porcine collagen, has been shown to
act as a scaffold for tissue formation but does
not encourage new bone formation. It preserves
ridge shape and size but with decreased bone
formation at 12  weeks compared with non-
augmented sites (25% versus 44%).58 Other
studies assessing this have given contradictory
results.59 The authors speculate that this
material may be used commonly, despite
these equivocal results due to ease of use and
marketing. Evidence suggests no difference in
ARP between the use of membranes alone or
membranes and deproteinised bovine bone
material (DBBM).13,60
Alloplasts and growth factors
Examples include hydroxyapatite, tricalcium
phosphate, calcium sulphate, bioactive glass
polymers, polylactic acid, polyglycolic acid or
collagen sponges. The materials are inert and
work via osteoconduction.
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Restorative dentistry
Vital bone content:
three months onwards
(%)
41.07
35.72
29.93
45.53
Hydroxyapatite in combination with
tricalcium phosphate, for example,
Straumann Bone Ceramic, has shown
similar results compared with DBBM when
comparing alveolar bone crest levels assessed
radiographically up to 32 weeks, histological
assessment of sites at eight months, bone
height, buccal and palatal wall thickness and
the need for further grafting or periodontal
indices around implants at one-year follow-up.
A statistically significant difference of 1 mm
in ridge width at eight months favouring the
alloplast was found.61,62,63
Calcium sulphate has been shown to
yield significantly less resorption and more
mineralised bone when used in conjunction
with platelet-rich plasma. 64 When this
combination was compared with a collagen plug
alone, a significant difference in new vital bone
of 66.5% versus 38.3% was found, respectively,
at three months but no difference in ridge
dimensions.65 Combining calcium sulphate with
allografts does not appear to aid ARP.66
Sockets preserved with Bioglass, a silicate
based glass, have shown a complete absence
of new bone formation within the first six
months, with lamellar bone infill at seven
months.67
Hydroxyapatite has been shown to yield
31% vital bone at 6–8 months.68 Polylactic or
polyglycolic acid (synthetic co-polymer) or
collagen sponges can also be used and can be
impregnated with other materials. Synthetic
co-polymer sponges have shown similar ridge
dimensions at three and six months compared
with no ARP. The sites showed mineralised,
well-structured bone with no residual graft
material. 69,70 Additionally, the Bio-Col
technique involves placing DBBM particles
followed by a collagen plug or membrane
and has been shown to allow for implant
placement.71 Collagen sponges combined with
hydroxyapatite and cell-binding peptide or
bone morphogenic protein have significantly
higher mean bone density and greater bone
augmentation (up to 2 mm mean ridge width)
CLINICAL
Amount of remnant Amount of connective
graft material: three tissue: three months
months onwards (%) onwards (%)
– 52.53
19.3 44.42
21.75 51.03
13.67 38.39
than collagen sponges alone.72,73 The addition
of these proteins also meant sites were half as
likely to require further grafting at implant
placement. Similar percentages of bone vitality
and ridge height changes were found.
Membranes and bone substitutes may,6,7,8,12,74
or may not, 3,13,14,75 preserve more bone
than bone substitutes alone, but it must be
emphasised that the difference is not clinically
significant.
Collagen sponges
C o l l a g e n s p on g e s , for e x amp l e ,
Haemocollagene, are usually type  1, non-
denatured, freeze-dried collagen of bovine
origin. They offer wound protection, blood
clot stabilisation and facilitation of granulation
tissue formation. These materials completely
resorb within two weeks to three months.
They can come in bullet shapes for ease of
placement in sockets, and are cheaper than
bone substitutes.
Although collagen sponges provide
favourable bleeding control and graft
protection, use of sponges alone appears to offer
limited benefit compared with naturally healed
sockets.76 Collagen sponges covering Bio-Oss77
and Puros78 (cancellous mineralised allograft)
appear to offer significant ARP compared
with extraction only.77,78 Gentamycin-soaked
collagen sponges covered with free gingival
grafts appear to offer borderline ARP compared
with atraumatic extraction.79
Materials summary
Limited evidence is emerging to differentiate
the various materials available.59 Findings
from a recent systematic review of randomised
control trials are summarised in Table  5.80
Other emerging materials, such as growth
factors, human platelet-derived materials,
platelet-rich fibrin, stem cells, cell therapy,
enamel matrix derivatives and bone marrow
require further evidence for validation.80
DBBM-containing materials covered by a
membrane can currently be considered the
 CLINICAL Restorative dentistry

Fig. 4 An example of soft tissue grafting at time of extraction of 22 and 23 sites a) Pretreatment. b) Teeth extracted atraumatically. c Connective
tissue graft with epithelialise collar sutured in situ. d) Wound closure. e) Buccal view of closed wound. f) Palatal site with dressing in place. g)
Site after four weeks healing buccal view. h) Site at four weeks healing occlusal view

Fig. 5 ARP of 11. a) Pre-treatment. b) Socket following atraumatic extraction of 11 and mechanical debridement. c) Deproteinised bovine bone
material and porcine collagen ‘plug’. d) 11 socket packed with bone graft material. e) 11 socket after closure with sutures. f) 11 socket one week
after ARP. g) 11 socket two weeks following ARP

Fig. 6 ARP of 12. a) Extraction of 11 and 12. b) Placement of Bio-Oss in 12 socket. c) Placement of Mucograft over 12 socket

‘gold standard’ due to ready availability, lack
of reported transmissible diseases, clinician
acceptance and lasting effect.
Nevertheless, until more conclusive evidence
is available, the choice will likely come down to
operator preference, experience, case selection
and material availability. Further research is
required to assess any tangible differences in
outcome between materials and methods.
Slower resorbing bone substitutes, such as
DBBM and bioactive glasses, appear to be
preferable for longer planned delays in implant
placement.
Socket sealing
This involves placement of a graft in the
socket which is fully covered. Sockets may
be sealed with coronally-advanced flaps,
free or pedicle soft tissue grafts, ADM (for
example, AlloDerm), xenografts (for example,
Mucograft) or collagen sponges (for example,
Haemocollagene). The need for primary closure
to improve ARP outcomes is debatable from
the literature, with some authors presenting
results in favour of socket sealing,6,7,8,12 while
others presenting results not in favour.3,13,14,75
However, particulate bone substitutes could
easily become dislodged from extraction
sockets, and some resorbable membranes

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© The Author(s), under exclusive licence to British Dental Association 2019
 Restorative dentistry CLINICAL

Fig. 7 ARP of 37. a) Pre-operative radiograph showing 36 due for extraction and ARP. b) 36 sectioned. c) Use of periotome. d) Loosened
fragments removed with no bucco-lingual force. e) Degranulation of sockets. f) DBBM with collagen ready for use. g) Sockets packed with DBBM
and collagen mixture. h) Membranes held in situ with sutures. i) Socket healing at two week review

Fig. 8 ARP of 22. a) 22 due for extraction and ARP due to vertical root fracture. b) Tooth extracted whole. c) Socket with buccal wall intact. d)
Degranulation of socket. e) Porcine (Mucograft Seal) Membrane. f) DBBM in socket. g) Socket sealed with membrane. h) Site after three months
healing with resin-retained bridge in situ showing buccal concavity of ridge 22 and highlighting instance of potential unpredictability with likely
need for further grafting

require complete coverage, for instance,
Bio-Gide. Raising a full thickness envelope
flap and making adequate releasing incisions
would allow tension-free coronal advancement
with primary closure. The disadvantage of
moving the mucogingival junction coronally
could be subsequently overcome by apically
repositioning a full thickness flap, either at first
or second stage implant surgery.
An alternative technique is to use the hard
palate to provide access to free and pedicle grafts.
Free gingival grafts can be harvested with soft
tissue punches of the appropriate size to cover
the socket. Pedicle flaps are harvested from
the palatal surfaces of the extraction socket,
staying 3 mm away from the gingival margins of
adjacent teeth. This is only suitable for maxillary
teeth, and reduces the number of surgical sites
and time. The pedicle will have its own vascular
supply compared with free grafts. Xenografts
can also be used and offer the advantage of
colour match and no donor site morbidity.
Mucograft Seal is a porcine-derived collagen
membrane designed for primary closure in ARP.
This membrane is thicker than the membranes
used for regeneration and is designed to be left
exposed to the oral environment.

BRITISH DENTAL JOURNAL | VOLUME 227 NO. 4 | August 23 2019 271

© The Author(s), under exclusive licence to British Dental Association 2019
 CLINICAL
Fig. 9 ARP of 22. a) Pre-operative view of 22 due for extraction and ARP. b) Socket with buccal wall intact. c) Degranulation of socket. d) Socket
packed with DBBM. e) Porcine (Mucograft Seal) membrane in place. f) Sutures in place. g) Healed ridge
Soft tissue grafting
Autogenous free gingival grafts and sub-
epithelial connective tissue grafts appear to
offer most predictable soft tissue grafting to
preserve or gain keratinised tissue,81 when
compared with resorbable membranes. 82
Resorbable membranes offer the advantage
of reduced morbidity and less surgical time.
The colour match of the graft to adjacent
tissues is also generally better with resorbable
membranes compared to free gingival grafts.
Soft tissue grafting can be performed flapless
or with minimal coronal advancement. A
socket graft, for example, a collagen sponge,
can be placed in the socket to support the
soft tissue graft. Healing occurs in six to eight
weeks, at which time implant placement can be
commenced. Figure 4 shows placement of a sub-
epithelial connective tissue graft at extraction
of the left maxillary lateral incisor and canine
and coronal advancement with primary closure.
Socket shield technique
This is one type of technique that falls
under a group of techniques termed ‘partial
extraction therapies’ which also include the
root submergence technique and pontic
shield. These therapies aim to maintain the
alveolar tissue using teeth themselves.83 The
socket shield can act as an alternative to ARP,
where a thin section of tooth is left in situ on
the labial aspect and an implant is inserted
into the socket on the palatal aspect of the
tooth. The aim is similar to ARP in terms
of maintenance of the buccal bone contour.
Histological assessment of beagle dogs has
272 BRITISH DENTAL JOURNAL | VOLUME 227 NO. 4 | August 23 2019
© The Author(s), under exclusive licence to British Dental Association 2019
Restorative dentistry
shown cementum to regrow on the palatal
aspect of the root fragment and onto the
implant.84 Despite good implant survival rates
at 4–5 years, with less than 0.5 mm vertical or
horizontal bone loss in maxillary first premolar
sites in ten patients, current four-year success
rates are 80.5%.85,86 An alternative technique
is the pontic shield, where part of a tooth is
again left in situ; however, the socket is grafted
instead of an implant immediately being
placed, with a view to using the site underneath
as a pontic. These techniques require further
evidence for validation for routine clinical use
and are mentioned here for completion.86,87
Clinical procedure
Based on the literature, it is difficult to give a
precise protocol as there is no support for one
technique over another. However, taking the
evidence available into account, the authors
would suggest the following protocol.
Pre-operative assessment of periodontal
probing depths, bone sounding and
radiographs can guide the clinician as to the
likely anatomy of the socket. However, this
should be confirmed clinically after tooth
extraction before proceeding with ARP.
It has been reported that the effect of raising
a flap on bone resorption remains unclear,
however other studies have shown that the
elevation of a full thickness flap can cause
resorption of thin bone walls.30,37 This may
occur as the buccal bone receives its blood
supply from the periosteum and disruption
of this affects its nutrient supply. The authors
would advise avoiding raising a flap when
planning ARP wherever possible.
With all methods, it is important to
maintain an atraumatic extraction technique,
maintaining as much bone as possible. Avoiding
expansion of the socket can minimise the risk
of fracturing thin bony walls. Applying circular,
rotational or bucco-lingual forces with forceps is
best avoided.30 Fine luxators, periotomes, piezo
surgery and vertical tooth extraction systems
may prove useful in this regard, although these
are more relevant to individual, conical, straight
roots. Multi-rooted teeth can be sectioned to
aid extraction. The authors suggest avoiding any
elevation or expansion on the buccal aspect in
order to minimise the risk of any fractures of
buccal bone. A common method for ARP is
described below (Figures 5, 6, 7, 8, 9).
Following tooth extraction, if existing
granulation tissue is present this should be
physically removed via debridement with a
surgical instrument. Some operators prefer to
irrigate the socket with saline, however a split-
mouth study of 75 patients undergoing third
molar extraction found a 3.5 times increased
incidence of alveolar osteitis when irrigating,
which could be due to the associated blood
clot disruption.88 The authors suggest avoiding
saline irrigation for this reason. Subsequently,
enough grafting material to fill out the
socket should be packed gently in, using an
aseptic technique. The sockets should not be
overfilled.89 Some clinicians prefer to moisten
the graft material with saline or blood before
use, in order to improve the handling. As the
material picks up moisture in the socket, it will
become easier to pack but others feel moistening
the graft will reduce the capillary action of blood
absorption onto the graft. The authors advise
to place the graft material dry or to moisten

it with blood rather than saline. Following
placement of the graft material, it is beneficial
to place sutures to help to hold the soft tissues
in place. Additionally, cross sutures can help to
stabilise the graft material. As an alternative, a
membrane can be placed over the graft material,
although it can be difficult to achieve primary
closure to gain maximum benefit from the use
of a membrane. A coronally-advanced, free or
pedicle soft tissue flap, or xenograft materials
can be used to achieve primary closure. This
could be fixed in place with interrupted sutures.
The authors advise utilising a membrane that
has been designed to be left exposed to the oral
cavity in order to seal the socket. This avoids
the extra time and morbidity associated with
either a coronally-advanced, free or pedicle flap
and aids stabilisation and protection of the graft
material from the oral cavity.
Routine post-operative instructions should
be provided to the patient regarding analgesia
and oral hygiene measures. The authors
do not advocate the routine prescription
of antimicrobials for ARP, given the risk of
antimicrobial resistance and side effects.
Sutures should be removed as soon as the
wound is stable enough to decrease bacterial
ingress and risk of wound infection.90 In the
authors’ experience, this is usually seven to ten
days post-operatively.
Conclusions
ARP can be a beneficial method for maintaining
bone volume to aid prosthetic delivery of
implants. It is likely to maintain around
2 mm of bone width and height. A variety of
materials and methods are available, which are
summarised in this paper. Further research
is still required to establish the influence of
patient factors and different materials on
ARP outcome, in addition to the long-term
stability of graft materials. ARP would appear
to be advantageous in cases where implant
placement needs to be delayed, for example
in young patients in whom growth is not
yet completed, and for pontic sites around
bridges. Slower resorbing graft materials,
such as DBBM and bioactive glasses, would be
preferable if the delay in implant placement is
protracted by more than nine months. Implant
outcomes in ARP appear to be comparable to
immediate, early and delayed approaches. ARP
could potentially reduce the need for a sinus
lift. Complete preservation of the alveolar ridge
after extraction is unlikely to be achieved, even
if ARP techniques are used.
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Restorative dentistry CLINICAL
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